CHAPTER 9. MEDICAL SERVICES
The types of medical services needed for a film production vary
depending on the locale, available local medical resources, and the types
of medical risks.
TYPES OF MEDICAL CARE
There are two basic types of medical care of concern in film
production: non-emergency medical care, and emergency medical services.
First aid is not medical care, but is emergency supportive treatment.
Non-Emergency Medical Care
On any film production involving large numbers of people, there will
be a variety of non-emergency medical problems such as cuts, bruises,
allergic reactions, minor illnesses, etc. which are amenable to normal
medical care. These types of medical problems can be treated by Family
Practice Physicians who are trained in basic medical care, or by primary
care physicians specializing in such areas as internal medicine or surgery.
Preferably, they should have passed a series of examinations to become
board-certified in their respective specialties. Further information on
the training of Family Practice Physicians can be obtained from the
American College of Family Practitioners (see Resources).
Emergency Medical Care
Medical emergencies are also a potential problem on any film shoot.
These emergencies can range from minor problems like sprained ankles up to
major problems like heart attacks, severe injuries, or even disasters. If
there are hazardous stunts or special effects planned for the film, the
risk of a major medical emergency is higher. Medical emergencies should be
treated by Emergency Physicians who are specifically trained to handle
these types of medical problems. To specialize in Emergency Medicine, a
physician should undergo residency training in emergency medicine, and must
pass a series of examinations to become Board Certified in Emergency Medi-
cine. Most emergency departments of hospitals have Emergency Physicians on
staff.
First Aid
The purpose of first aid is to administer emergency supportive
treatment before the injured person can get to a physician. First aid is
not medical treatment. It is intended to keep the person alive until they
can get definitive medical treatment. First aid can also be used to attend
to minor cuts, bruises, etc. where medical treatment is not necessary.
In the United States, there are a variety of state-certified levels
of expertise for first aid practitioners. The lowest level is certified
first responder with 40 hours of training. In increasing order of training
are basic EMT (Emergency Medical Technician), EMT intermediate, EMT
critical care technician, and EMT paramedic. EMT intermediate and higher
levels must work under a physician's supervision. This can be by radio or
telephone, and most hospital emergency departments maintain facilities for
such supervision. EMT basic and certified first responder can immobilize a
patient for transportation, bandage wounds, do CPR and similar classic
first aid measures. They cannot give oxygen or medication, give intrave-
nous solutions, read electrocardiograms, use a defibrillator, or use most
other resuscitation equipment.
Nurses, although often used on motion picture sets, must work under a
physician's direct supervision in order to do more than carry out basic
first aid. Unless they have had special training in advanced first aid,
nurses do not have the training or expertise of advanced EMTs.
NEEDS ASSESSMENT
The first step in planning medical care for a film shoot is to
undertake a needs assessment to identify potential medical risks. This
assessment and subsequent planning and implementation steps should be
carried out by, or with the assistance of, an Emergency Physician. Non-medical personnel are just not qualified to make the necessary evaluations
and decisions.
In the United States or Canada, the production company should contact
the American College of Emergency Physicians for information on local
emergency medical services, and help in making an evaluation. The Chairman
of the nearest Department of Emergency Medicine in a university hospital
should be contacted to provide information on local standards of care,
emergency services, and as a referral source for other medical specialties
that are available in the community.
In other countries, particularly underdeveloped countries, the level
of emergency and even non-emergency medical care might be well below
American standards. In such cases, medical service companies specializing
in providing emergency and non-emergency medical services for motion
picture production around the world can be of invaluable assistance.
Information on medical care in other counties can be obtained from the
Centers for Disease Control in Atlanta, Georgia, the State Department in
Washington, D.C., and the World Health Organization in Geneva, Switzerland.
(See Appendix 4 at the end of the book.)
An adequate needs assessment involves looking at a number of crucial
factors, as discussed below.
Script
The script should be reviewed to determine possible high risk
situations, such as hazardous stunts, underwater activities, and other
action sequences. Once these risks are identified, steps can be taken to
determine safe procedures. This was discussed in Chapter 6.
Location
Once the filming locations are chosen, then there has to be an
evaluation of the planned locations to determine potential medical hazards.
Hazards related to the filming on location could include possible safety
hazards, asbestos exposure, etc. in old, abandoned buildings; accidents in
mountainous areas; heat-related diseases in deserts; frostbite in cold
weather conditions; drowning in rivers; and a wide variety of other
hazards. (See Chapter 3)
When filming on location, there is also concern about unusual local
health hazards. For example, in foreign countries, there would be concern
about vaccination requirements, possible current epidemics or other local
endemic diseases (such as dysentery, typhoid, etc.).
In addition, there would have to be an evaluation of the quality of
locally available medical care and medications, and an analysis of local
hospitals, clinics and emergency transportation services.
If the film or television production is shot in a major urban city
like New York City - either on stage or on location - then the level of
local medical care should meet modern standards of medical practice. The
needs assessment would then primarily involve determining what accredited
hospitals and clinics and emergency transportation systems are available.
This would include the location of the closest Level 1 trauma hospitals in
case of major accidents, or burn centers in case of severe burns.
If the local facilities do not meet modern American medical
standards, then more extensive on-site medical care would be needed, as
will be discussed later. In addition, the location of the nearest source
of quality medical care would have to be determined.
Personnel
The number of people working on the stage or location - including
actors, camera crew, preproduction crew, grips, etc. - and the anticipated
filming time also can affect the potential for medical problems and level
of needed medical facilities and care. The use of any high risk actors,
such as children, the elderly, disabled, etc. should be identified so
special precautions can be developed as needed.
PRE-PLANNING PHASE
After the initial needs assessment is done, then a detailed analysis
of major hazards and risks is necessary, followed by the design and
implementation of a comprehensive plan of action.
Emergency Planning
An essential step is the development of a plan for emergencies, which
can range from individual problems, such as heart attacks, to disasters
affecting many people, such as a stunt car driving into a crowd or a
building collapse. This should involve meeting with local police and fire
departments and other relevant authorities concerning required permits and
the coordination of emergency procedures. This is especially important in
connection with stunts and special effects involving fires and explosions.
Meetings should be arranged with local hospital and emergency
transportation authorities to arrange and coordinate speedy medical care in
case of emergencies. Steps should be taken to eliminate lengthy waiting
periods in hospital emergency rooms through expedited arrangements well in
advance of filming. Also particular emergencies might mean transporting
injured or ill individuals to different hospitals. For example, different
hospitals might have intensive care units for heart attacks, trauma
centers, and burn centers. If these are not available locally, then
arrangements should be made in advance for emergency transportation and
treatment at appropriate hospitals in other locations. If local emergency
transportation systems are not adequate or speedy enough, then private
arrangements will have to be made.
Non-Emergency Medical Care
As discussed earlier, there will be a variety of non-emergency
medical problems on a film set which are amenable to normal medical care.
Arrangements should be made with local hospital authorities and perhaps
private physicians to provide this medical care. These arrangements should
include what types of care will be provided, at what cost, and how it will
be paid. If such care is not available within a short distance (e.g. in
the country), then on-site medical care might be arranged. Besides
providing prompt treatment, this has the advantage in many instances of
decreasing costly lost time.
Foreign Locations
When filming in other countries, a number of other potential medical
problems and risks can arise. Vaccinations, immunizations, health
screening and certificates of health might have to be arranged and
provided. Local medications might not be in the same dosages as in the
United States and the quality might not meet current American standards.
Water sources might have to be tested and perhaps arrangements made for
providing safe water. The level of medical care in the foreign country
might not meet the American standard of care, possibly requiring a more
complete on-site medical presence than would otherwise be necessary.
ON-SITE MEDICAL CARE
The level of on-site medical care that is needed depends on the risks
and the availability of adequate emergency and other medical treatment.
Availability of Emergency Medical Care
In cases of severe injuries, the time taken to receive qualified
trauma care is critical. Most emergency medical service experts believe
that emergency or trauma care should be available within 10 minutes. If
proper medical care can be reached within this time, then first aid
facilities may be all that is needed on-site for all but the most hazardous
situations. This would be true, for example, in most urban settings in the
United States. If reaching medical care would be delayed, then a board-certified Emergency Physician would be needed on-site.
Guidelines for Medical Care on Location
As mentioned, the level of on-site emergency medical care needed
depends on the degree of risk and the availability of emergency medical
treatment.
If the risk of injury is high, for example, in a stunt involving
exploding cars, and if it would take more than 10 minutes to reach a Level
1 trauma hospital, then properly qualified Emergency Physicians, and
supporting equipment and personnel, should be on location in order to be
able to provide crucial emergency medical treatment. If the risk is high,
but proper emergency medical facilities can be quickly reached, then
currently certified paramedics on-site would be acceptable.
Even when there are not specific high risk situations, accidents and
severe illnesses such as heart attacks requiring quick medical attention
can occur. If emergency medical treatment is not quickly available, such
as on remote locations (especially in foreign countries), then properly
qualified Emergency Physicians are recommended, just as for high risk
situations. These physicians can also provide routine medical care for
non-emergency situations such as minor accidents and illnesses which,
although not serious, can result in costly lost time. If adequate medical
treatment is readily available, then certified EMTs should suffice for
possible emergencies like heart attacks. For this situation, an EMT
intermediate level would be sufficient. Although not mandated by law,
supervision by an Emergency Physician is recommended.
The following summarizes minimum recommendations based on the type of
filming situation. These recommendations are based on discussions with
Emergency Physicians and other physicians familiar with the medical needs
of motion picture production.
1. Sets with no stunts, special effects or other high risk situations.
U.S. - within 1 hour of adequate medical care: EMT intermediate
level, preferably physician supervised.
Remote U.S. or other developed countries: Board Certified Emergency
Physician
Underdeveloped countries: Board Certified Emergency Physician,
preferably trained in tropical medicine/infectious diseases.
2. Sets with hazardous stunts or other high risk situations.
U.S. - within 1 hour of adequate medical care: State-certified EMT
paramedics in radio communications with a supervising physician.
Remote U.S. or other developed countries: Board Certified Emergency
Physician.
Underdeveloped countries: Board Certified Emergency Physician,
preferably trained in tropical medicine/infectious diseases.
Emergency Transportation
It is crucial that adequate emergency transportation be available for
accidents and other medical emergencies. An ordinary car, station wagon or
helicopter is not adequate. The emergency vehicle should have an advanced
life support unit and must be staffed by trained personnel. In stuntman
Dar Robinson's fatal accident while filming a motorcycle scene in 1983,
part of the reason for his death was that he was transported a great
distance in a station wagon by untrained personnel who did not know how to
immobilize him properly.
For high risk situations, it would not be advisable to rely on local
ambulance services because of the delay in their reaching the scene of the
accident. There should be one on location in case of accident, even in
major cities like New York. For normal situations, it should be possible
to rely on local ambulance services if they meet appropriate standards.
However, arrangements should be made in advance to meet possible
emergencies.
In remote locations, a properly equipped emergency vehicle like an
evacuation helicopter should be on hand for high risk situations, if an
ambulance could not reach proper medical facilities quickly enough.
Emergency transportation services should be on call for normal emergencies,
unless it would take too long for them to reach the location; in that case
the emergency vehicle should be on hand.
Most states have regulations concerning emergency transportation
vehicles. In New York State, for example, both the emergency equipment on
board and the mechanical safety of ambulances must be state-certified. The
ambulance must also have a 10 inch side sticker stating it is NYS certified
and a signed certification logo. In addition the ambulance personnel must
consist of a driver plus at least one (and preferably two) state-certified
EMT Basics. Evacuation helicopters should meet the similar standards. In
New York State, ambulance standards are also applied to evacuation
helicopters.
COST OF MEDICAL CARE
Besides the effect on an individual's health, accidents and illnesses
can have a variety of practical and financial repercussions, including the
cost of health care, possible lawsuits, increases in liability and workers'
compensation insurance rates, and cost overruns due to delayed production.
A properly designed on-site medical care program can save money in a
variety of ways:
1. In case of a major accident or injury, the availability of trained
emergency medical personnel and needed equipment can mean the difference
between a fatality and a simple filming delay.
2. Proper preventive measures and on-site medical care can prevent
illnesses from breaking out or minimize the loss of production time if they
do occur, especially with respect to minor illnesses and injuries which can
be treated on-site. Proper and prompt medical treatment can also shorten
periods of more severe illnesses, again leading to decreased downtime.
3. Decreases in work-related illnesses and injuries can lead to reduced
workers' compensation rates and lower overall medical costs.
4. A professional emergency medical program can lead both to decreased
liability insurance rates and to overall lower liability risk. Such a
program is good faith evidence that a production company is trying to
provide high quality medical care.
5. A comprehensive approach to emergency medical care can also lead to
reduced costs for medical goods and services. The cost of medical care on
a case by case basis is usually more expensive than a properly planned
medical program with many costs worked out in advance. In addition, many
production companies have spent money on equipment and supplies that were
not needed.
REFERENCES
McCann, M. (1988). Emergency Medical Care on Set and Location. Center for
Safety in the Arts, New York.